Medical Archaeology

Military Medicine in the Crusaders' Kingdom of Jerusalem

Eran Dolev MD1 and Nachshon Knoller MD2

1Department of Internal Medicine E, Tel Aviv Sourasky Medical Center, and 2Department of Neurosurgery, Sheba Medical

Center, Tel-Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Israel

Key words: military medicine, Crusaders, medieval medicine

IMAJ 2000;3:389-392

Historical background

The Crusades represent one of the most fascinating adventuresin western history. Inspired by Pope Urban II at the Council ofClermont on 27 November 1095, thousands of Europeans madetheir way to the East to liberate the Holy Land from the reign ofIslam. After capturing Jerusalem on 15 July 1099 theyestablished a Crusaders' Kingdom in the Holy Land that ruledthe country or parts of it for about 200 years, until the fall ofAcre on 15 May 1291 [1].

The conquest of the Holy Land and other territories in theMiddle East led to an ongoing encounter with the localheterogeneous population. These encounters, which took placein peacetime as well as on various battlefields, left their mark onboth societies ± the European and the native. Commercial,economic and agricultural relations influenced the daily life andthe entire social infrastructure of the area [2].

Medicine was probably the sphere in which the Europeanimmigrants benefited most from their contacts with the East,with the Latins (as the Europeans were called) acquiringmedical knowledge from the local practicing physicians [3].

European medicine during Medieval

times

The main development of European medicine during the MiddleAges began in the eleventh century at the Salerno MedicalSchool in southern Italy. In 1076 the area was conquered by theNormans, which further contributed to the development of thisschool. As a result of contact with the Arabs of North Africaand Spain, classic Greek medicine returned to Europe [4]. Theinfluence of the medical school at Salerno was the dominantfactor in the development of European medicine from the tenthuntil the sixteenth century [5]. However, during the twelfth andthirteenth centuries, the era of the Crusaders' Kingdoms,Islamic medicine practiced in the East was in many respectssuperior to western medical practice. Muslim surgery alsolargely impacted upon surgical practice at Salerno. Albucasis'Altasrif: a treatise on the practice of surgery, became the

standard textbook of surgery taught at Salerno and remained sofor a long time [6]. Byzantine medicine, which derived fromNestorian medicine in the fourth century, was later influencedby advances in the neighboring Muslim countries. It attained itsheight during the twelfth and thirteenth centuries, influencing inturn various aspects of medical practice in the Crusaders'Kingdom, especially military medicine [7].

The main culprit for the backwardness of surgery inChristian society was the attitude of the Church. According toChristian thinking of the time, the spilling of blood violated theprinciple of the sanctity of the human body. At the council ofTours in 1163 for example, the pronouncement ``Ecclesiaabhorret a sanguine'' (the church does not shed blood) meantthat surgery could no longer be practiced by physicians, whoessentially were also clergymen [8]. This view was in contra-diction to the church's general attitude to medicine, which wasin favor of surgical intervention as reflected in the church'swritings: ``We would not require the medical art for relief if wewere immune to disease.'' Thus, ``The medical art was given tous to relieve the sick, in some degree at least'' [5].

Crusader military medicine

The Crusaders' Kingdom lived by its sword and knew fewperiods of peace. What emerged from their numerous engage-ments with the Muslims on the battlefield were the developmentof traumatology and surgery and the organization of militarymedicine.

The unique innovation of the Crusaders' Kingdom ofJerusalem was the creation of military orders. While mostprevious monastic orders had dedicated themselves exclusivelyto the Church, the Knights in the Crusaders' Kingdom, whobelonged to several military orders, were committed to the sickand poor. The Order of the Knights of St. John of Jerusalemwas established as a charitable institution to care for indigentpilgrims; when the Crusaders captured Jerusalem this organiza-tion was already functioning [9].

The first master of the organization, ``Blessed Gerard,''acquired immediate recognition by Godfrey, the first king of the

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Crusaders' Kingdom. The organization became a military orderand its members took the vow ``to be a serf and a slave to ourlords the sick,'' which meant caring for the sick and poorregardless of race, language or religion [9]. Raymond du Puywas the first to hold the title of Master of the order. He taughtthe knights that ``it did not suffice to live piously and givemedical aid to pilgrims'' [3].

Considering the continued power of the Muslims and theconstant danger still menacing Christian travelers, the Knightsof St. John had to be prepared to die, if need be, in defense ofthe sick, the wounded and the pilgrims [9]. In 1112 KingBaldwin I of Jerusalem declared that the Order be called ``TheHospital'' and its members, the Knights of St. John ofJerusalem, be known as ``Hospitallers.'' He also legalized thestatus of all possessions owned by the Order in the Kingdom,which were further exempted by the Patriarch of Jerusalemfrom the payment of tithes. All these efforts were aimed atreinforcing the hospital's medical work among the pilgrims. TheOrder was recognized by Pope Pascal II in his bull issued in1113 [9].

Without doubt the greatest achievement of the Order of St.John was the foundation of the hospital in Jerusalem. Thisfacility served as a prototype for several other hospitals [10].Knights from the aristocracy were also involved in caring forthe poor and sick, and the care was given with unstintingdevotion and at considerable expense [11]. The hospital's abilityto function in the context of military medicine is supported byevidence that after the battle against the Muslims at Tel Gezer(Mongisard) on 25 November 1177, about 750 battle casualtieswere evacuated from the battlefield and were admitted to thehospital in Jerusalem within 24 hours [9].

There is no direct information regarding the process ofdiagnosing diseases or the medications that were prescribed forvarious conditions, since the archives of the orders and of theKingdom itself were lost. However, several methods werementioned, all in the tradition of Salerno. Thus, urineexaminations were considered to be of great value, althoughthe drinking of water was not thought to be important. Dietswere prescribed according to the Salernitan code. Bloodlettingwas frequently practiced [5]. Several methods can be attributedto Byzantine influence [10]. Doctors serving the sick brotherswere usually not members of the religious orders but wereoutside practitioners [12]

The medical regulations of the order of St. John, which werein the spirit of Salerno, also reveal a close affinity to the medicalpractice in Muslim hospitals [3,13,14]. The earliest collection ofthe hospital's rules and regulations has been attributed to thealready mentioned Raymond Du Puy, the second master of theOrder (1120±1160). In this code only chapter 16 describedservices provided exclusively for the sick [14]. Later on, around1181, specific regulations were given by Roger de Moulins, theGrandmaster of the Order at that time. The hospital wasdivided into wards. Four doctors and four surgeons adminis-tered to the sick and were assisted in each ward by ninesurgeants (the equivalent of medical orderlies today) [15]. The

medical and humanitarian work done by the Hospitallers wasmuch appreciated, not only by the pilgrims but even by the foe.When Saladin entered Jerusalem in October 1187 after he hadwon the battle of Hattin, he permitted the brothers of the Orderof St. John to care for their wounded until they were able totravel [9].

The Order of the Teutonic Knights was founded during thesiege of Acre in 1191. While this Order included German-speaking knights, its goals and the regulations were similar tothose of the Order of St. John of Jerusalem. After receivingrecognition by Pope Innocentius III in 1199, its hospital wasbuilt in Acre [16].

The Order of St. Lazarus was the military order of leperknights. Taking its name from Lazarus, the leper who was curedby Jesus, the knights of this Order devoted themselves to thecare of other lepers, but also took upon itself all the obligationsand duties of a military order. The Order of St. Lazarus alsofounded a special hospital located at the northern wall ofJerusalem [17].

The Crusaders at war

The principal weakness of the Crusaders' Kingdom was the lackof manpower. Thus, they were very cautious in warfare,preferring to defend fortified positions than engage in openbattle [18]. This strategy is exemplified by their dependence oncastles [19], which were well prepared for siege and weremanned and equipped accordingly. The knights therein couldthus lead a regular albeit communal life, and were ready at anymoment to resist an attack or send reinforcements to othercastles [20]. Moreover, several castles were organized fortending to battle casualties, although the details are unknown[21]. While the castle strategy was generally the rule, somemilitary engagements demanded that the knights fight in theopen, which necessitated charging and tested their battle ability

Siege warfare was popular on both sides ± Moslem andChristian. This mode of fighting was more advanced technolo-gically than the usual tactics, but its toll in human lives andinjuries was high. Siege warfare meant siege towers, belfries andthe use of mines [22,23]. In the siege of Acre for example, thebesiegers breached the tower and covered the walls with animalskins soaked in vinegar and mud in order to protect themselvesfrom the boiling water or oil that would be poured down by thecastle defenders [22]. During the siege of Arsuf (known today asRishpon, near Herzliya), the attackers succeeded in destroying atower that crushed a hundred men inside [23].

The basis of the Crusader army was the armored knight. Theknights constituted the body of heavy cavalry that served as thetactical unit for the attack [24]. At the start of an offensive theknights wielded lances, but when it came to hand-to-handcombat they used swords [25]. The Crusaders relied for victoryin battle on the mounted charge, however the Muslims were wellaware of the importance of neutralizing their enemy's horses.Moreover, the Muslims were light and mobile; they wouldoutflank the Crusaders' units in order to upset their cohesion.

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They could achieve this only after killing or wounding theenemy's horses. The Muslims used arrows that were extremelyeffective in establishing superiority prior to physical contact[26]. In order to overcome the limitations of heavy cavalryfacing a highly mobile enemy, the knights' units wereaugmented by mounted and foot soldiers, among them archersand crossbow men [26].

The heavy armor of the knights, while used extensively inEurope, was far from suitable for the hot climate in this part ofthe world. In addition to the weight of the armor, the knightssuffered great discomfort from the hot metal.

At the level of the combat unit, wounded warriors wereattended to by non-combatants on an ad hoc basis. On severaloccasions the wounded were evacuated from the battlefield bythe devoted knights of the military orders to a castle or hospital[27].

The battle of Hattin, which took place in the region of theLower Galilee on 4 July 1187, serves as an example of animmense military disaster. That battle marked the totaldestruction of the military power of the Crusaders' Kingdomof Jerusalem, the loss of its capital Jerusalem, and most of itsterritories. The Muslim victory at Hattin became the symbol ofMuslim superiority over the Christians, though the real lessonof the battle could be defined as military incompetence duepredominantly to their disregard of the basic principles ofmilitary medicine that were certainly known by that time. TheCrusader army entered the battlefield, having left the watersources behind them and after a long march that had begunbefore dawn on a particularly hot day. During the march, longbefore any real engagement had occurred, the knights' unitswere attacked from afar by mobile archers whose arrowsinflicted injuries to both men and horses. They also burned thefields, causing demoralization and slowing the advance of theheavy units. When at last the knights reached the enemy, bothhorses and men were thirsty and exhausted. Many of the footsoldiers deserted. The knights who were deprived of the infantryremained exposed to the enemy, unable to charge or fighteffectively for their own lives. This disaster was monumentalbecause the Christian army that assembled for the battle atHattin was one of the largest in the history of the Crusades:most of the 1,200 knights and 10,000 infantrymen who marchedinto the battle were annihilated [28±31].

War injuries

The weapons used at the time of the Crusades ± the lance, thesword and the dagger ± were designed to kill. Penetratingwounds of the chest or abdomen were usually lethal, althoughsome victims survived them. Bleeding to death from injuries inthe neck region or extremities occurred frequently as theseregions were less protected than the others.

The Crusaders used heavy broad swords which, held in twohands, rendered amputations and wide penetrating wounds. Incontrast, the Muslims used thinner and longer curved swordswith very sharp blades. Held in one hand, these could inflict

deep penetrating wounds. Knights who were thrown from theirhorses sustained fractures, some of them compound fracturesthat did not heal easily. In some cases the injured horses fell andcrushed their riders to death [32].

The most important historian of the Crusaders' Kingdom ofJerusalem was William the Bishop of Tyre. As an eyewitness tomany of the events reported in his book, his descriptions wereaccurate and his interpretations in accord with the beliefs andattitudes of the time. The books of William of Tyre also containseveral descriptions dealing with various aspects of militarymedicine. The story of King Baldwin I and his injury (July 1103)may serve as an example of early Christian surgical practice [33]:

They were hiding in ambush, but the king fell on themfiercely, killed most of them, and put the rest to flight.One of them, however, as he fled, hurled a javelin that byill luck struck the king. It entered from behind throughthe ribs near the heart and just missed dealing a fatalblow. The care of the physicians, however, with their useof incisions and cautery, at length restored Baldwin tosome degree of health, but at certain times, ever after hesuffered a recurrence of trouble from his wound.

Also recounted by William was the use of smoke as a militaryweapon and the suffocation that it caused [34], a case of heartinjury caused by an arrow [35], and cases of multi-trauma andfractures during the use of siege tactics [36]. He reported theresults of falling from a horse, such as fractures to limbs [37] orto the skull. It is not difficult to deduce the diagnosis of a skullfracture from his description of otorrhea [38]. William was wellaware of the importance of water, and that its lack should betaken into account when planning for battle [39]. He wroteabout the possible causes of epidemics in the military setting,such as might result from unburied corpses [40]. He alsorecommended the steps to be taken when an epidemic diseaseaffected the army, namely, isolation of the sick [41]. William ofTyre mentioned the use of stretchers for medical evacuationfrom the battlefield, but one cannot conclude from the textwhether stretchers were used for any injured soldier or wereexclusively reserved for injured knights and nobles [42±45].

Perhaps the first recorded case of post-traumatic stressdisorder may be attributed to Count Stephen of Blois, asevidenced by his behavior before the siege of Antioch ascompared to his conduct and attitudes after [46].

The heritage of Crusader medicine

The impact of Crusader medicine on European health profes-sions was quite significant. The Latins in the Holy Land learnedfrom the Muslim doctors about preventing diseases, a conceptutterly unknown in the West. For example, Gilberuts Angelicus,who participated in the third crusade wrote a book in which heemphasized the issue of hygiene, a subject he had learned fromthe writings of the great Muslim physician Rhazes.

Hugh of Lucca, known also as Hugo Borgogni, was asurgeon who participated in the fifth crusade as a member of theItalian expedition. During the siege of Damietta he had the

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opportunity to attend to many battle casualties and became anexpert in treating fractures. It is likely that his militaryexperience influenced his attitude against suppuration as anessential step in the process of wound healing. Hugo did notleave any written medical works. However, his pupil Theodoricof Cervia (1205±1298) wrote and published Chirurgia in 1267, abook considered to reflect Hugo's ideas on antisepsis anddebridement [47]. Theodoric was also credited for using spongessaturated with narcotic substances to obtain anesthesia duringoperations [48].

In closing, we would like to emphasize the major influencethat the Military Orders of the Crusader's Kingdom and theirhospitals had on European medicine. During the thirteenthcentury and later, hospitals began to be established in Europe,playing an essential role in many European communities. Boththe prevalent concepts of hospital organization and theprofessional attitudes are seen to closely resemble those of theoriginal institutions founded by the knights in the East.

References

1. The best general source on the Crusades:

Runciman S. A History of the Crusades. Vols. 1-3. New York: Harper, Torch

Books, The Academy Library, 1965.

The best general source for the history of the Crusaders' Kingdom is:

Prawer J. A History of the Latin Kingdom of Jerusalem. Jerusalem: Bialik

Institute Publishers, 1963 (Hebrew).

2. Benvenisti M. The Crusaders in the Holy Land. Jerusalem: Israel Universities

Press (Keter), 1970:27.

3. Woodings AF. The medical resources and practice of the Crusader states in

Syria and Palestine 1096-1193. Med Hist 1971;15:268±77.

4. Crombie AC. Augustine to Galileo. Vol 1: Science in the Middle Ages.

Cambridge, Mass: Harvard University Press, 1961:228±43.

5. Gordon BL. Medieval and Renaissance Medicine. New York: Philosophical

Library, 1959:314±21.

6. Campbell D. Arabian Medicine and its Influence on the Middle Ages. Vol.1.

London: Trubner & Co, 1926:151±72.

7. Garrison FH. Notes on the History of Military Medicine. Washington DC:

Association of Military Surgeons, 1922:79±80.

8. Smail RC. Crusading Warfare 1097-1193. Cambridge, UK: Cambridge

University Press, 1972:17.

9. Hume EE. Medical Work of the Knights Hospitallers of Saint John of

Jerusalem. Baltimore, MD: The Johns Hopkins University Press, 1940:4±8.

10. Miller TS. The Knights of Saint John and the hospitals of Latin West.

Speculum 1978;53:709±33.

11. Dolev E. A twelfth century hospital in Jerusalem. Harefuah 1980;99:136±7

(Hebrew).

12. Riley-Smith J. The Knights of St. John in Jerusalem and Cyprus, 1050-1310.

UK: MacMillan, St. Martin's Press, 1967:225.

13. Ibid. pp 335.

14. Delaville Le Roulx J. Cartulaire General de l'Ordre des Hospitaliers de S.

Jean De Jerusalem, 1100-1310. 4 Volumes, Paris, 1894±906.

15. Riley-Smith J. The Knights of St. John in Jerusalem and Cyprus, 1050-1310.

UK: MacMillan, St. Martin's Press, 1967:332.

16. Prawer J. The Crusaders: A Colonial Society. Jerusalem: Bialik Institute

Publishers, 1975:347±50.

17. Ibid. pp 354.

18. Beeler J.

Warfare in Feudal Europe, 730-1200. Ithaca, NY: Cornell University Press,

1971:130.

19. Marshall C. Warfare in the Latin East, 1192-1291. Cambridge, UK:

Cambridge University Press, 1992:93.

20. Benvenisti M: The Crusaders in the Holy Land. Jerusalem: Israel Universities

Press (Keter), 1970:277±83.

21. Ibid. pp 381.

22. Prawer J. The Crusaders: A Colonial Society. Jerusalem: Bialik Institute

Publishers, 1975:424±31.

23. Bradbury J. The Medieval Siege. Woodbridge, UK: The Boydell Press,

1994:248.

24. Marshall C. Warfare in the Latin East, 1192-1291. Cambridge, UK:

Cambridge University Press, 1992:48.

25. Ibid. pp 88.

26. Smail RC. Crusading Warfare 1097-1193. Cambridge, UK: Cambridge

University Press, 1972: 81±3.

27. Marshall C. Warfare in the Latin East, 1192-1291 Cambridge, UK:

Cambridge University Press, 1992:175.

28. Runciman S. A History of the Crusades. Vol II. New York: Harper, Torch

Books, The Academy Library, 1963:453±8.

29. Fuller JFC. A Military History of the Western World. Vol. I: From the

Earliest Times to the Battle of Lepanto. New York: Da Capo Press, Inc.,

1987:423±31.

30. Baldwin MW. Raymond III of Tripolis and the Fall of Jerusalem (1140-

1187). Princeton, NJ: Princeton University Press, 1936:96±135.

31. Smail RC. Crusading Warfare 1097-1193. Cambridge, UK: Cambridge

University Press, 1972:189±97.

32. Ficarra BJ. Disease to death during the crusades. In: Waserman M, Kottek

SS, eds. Health and Disease in the Holy Land. Lewiston, NY: The Edwin

Mellen Press, 1996:135±55.

33. William of Tyre. A History of Deeds Done Beyond the Seas. Babcock EA,

Krey AC, eds and trans. New York: Columbia University Press, 1943:Book

X, Chapter 26.

34. Ibid. Book X, Chapter 8.

35. Ibid. Book VI, Chapter 2.

36. Ibid. Book XIV, Chapter 3.

37. Ibid. Book XVIII, Chapter 25.

38. Ibid. Book XV, Chapter 27.

39. Ibid. Book III, Chapter 16.

40. Ibid. Book X, Chapter 28.

41. Ibid. Book IV, Chapter 17.

42. Ibid. Book III, Chapter 17.

43. Ibid. Book XI, Chapter 31.

44. Ibid. Book XII, Chapter 31.

45. Ibid. Book XVIII, Chapter 17

46. Ibid. Book VI, Chapter 10.

47. Theodoric of Cervia. Chirugia. Campbell E, Colton J, trans. New York:

Appleton-Century-Crafts Inc., 1955.

48. Edwards H. Theodoric of Cervia, a medieval antiseptic surgeon. Proc R Soc

Med 1976;69:553±5.

Correspondence: Dr. E. Dolev, Dept. of Internal Medicine E, Tel Aviv

Sourasky Medical Center, 6 Weizmann St., Tel Aviv 64239, Israel.

Phone: (972-3) 697-3705, Fax: (972-3) 697-4655,

email: dalia96@netvision.net.il

Erratum.

In the article ``Bolus high dose interleukin-2 for the treatment of malignant melanoma'' by Pappo et al., which was

published in the March issue (2001;3:169±73), the two panels of Figure 1 were inadvertently transposed. The bottom

figure labeled B should be the top figure and labeled A, and the top figure should be the bottom figure and labeled B.

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